When Robyn Bernstein, MD, started at the University of Michigan Medical School in 2021, she wanted to know how the school’s rollout of a new program to provide free mental health counseling for students was going.
The program was launched after a student had taken his own life in 2020, at the beginning of the pandemic. That student was a relative of Bernstein’s.
“This was personal to me, that we have something available to people,” she says. “Who knows if this would have helped him. I don’t know, but for me, this program honors his memory.”
Medical students report higher rates of depression and anxiety compared with their same-aged peers and are three times more likely to die by suicide than the general population is, according to the American Medical Association.
The University of Michigan conducted a needs assessment in 2020. After noticing high levels of reported burnout, the school listened to student feedback and identified the need for high-quality psychological counseling tailored for students. In 2022, as part of the new program, the school hired four full-time therapists to serve students at no cost. One year after the program was implemented, Bernstein conducted a survey to measure students’ self-reported mental health and their utilization and perception of the available resources. They found that, though burnout and mental health symptoms stayed consistent, a significant number of students reported using the program.
“This program increased resources,” Bernstein says. “It also started a dialogue among all the staff and doctors at the hospital.”
While medical student, resident, and provider mental health have long been topics of concern, the stresses of the COVID-19 pandemic shone a spotlight on the need for more support and a change in culture.
Scaling up services
At Indiana University (IU) School of Medicine, the largest medical school in the country, the number of student visits to school mental health providers was nearly double in the 2021-22 academic year, as compared with 2018-19. Before 2017, the medical school had only one staff psychologist dedicated to student well-being.
Providing access to mental health services was particularly challenging because IU School of Medicine is spread out across nine campuses, some of which are in rural areas, explains Samia Hasan, MD, a psychiatrist and director of mental health services for the school. After Hasan was brought in to build up the resources dedicated to student mental health, she made it a priority to make those services accessible.
“That was my mission,” she says.
As she added new therapists to the staff, appointments would fill up quickly, showing that there had previously been an unmet need, Hasan says. Over the past nine years, the team has grown from just two staffers to six full-time therapists, two administrative staff, a research assistant, and two part-time psychiatrists, including Hasan, who splits her time between clinical work and running the program.
In 2017, the first year of expanded mental health services, 19% of students used them at least once during their time in medical school. By 2023, that percentage reached 51% and has hovered around that level since. The services are also available to residents and fellows. By 2025, 37% of them used mental health services at some point during residency or fellowship, compared with just 7% in 2017.
To make this possible, Hasan says it was essential to offer flexible telehealth options, and to let students and residents know that their records were separated from the hospital’s records by a firewall, which is required by the medical school accreditation body, to ensure that their professors and peers cannot access this information.
Hasan’s team also teaches prevention workshops and made a series of videos interviewing faculty about their own mental health struggles, to help destigmatize getting help.
“There’s nothing more powerful than hearing one of your attendings talking about postpartum depression or alcohol use,” Hasan says.
She has spoken with other medical school administrators who are similarly scaling up their mental health offerings, but says that a formal, comprehensive assessment of how medical schools across the country are meeting student mental health needs is lacking.
“That is an area that has not been well published yet,” she says.
Making gains
In 2022, a working group of the AAMC Group on Student Affairs developed a set of recommendations for medical schools to adopt, including preparing students for the types of mental health-related questions asked on state licensure applications, establishing a policy for giving students schedules in advance, considering a pass-fail grading system, and conducting an annual assessment that solicits feedback from students. But in 2023, an analysis of three-quarters of U.S. medical schools’ policies found that just 47% met at least one guideline and only 13% had implemented all the recommendations.
Still, many institutions have made efforts to bolster the resources offered to students. One 2023 survey of 157 medical schools found that 124 of them offered free therapy sessions for students.
“I’ve been doing this research for 25 years or so,” says Liselotte Dyrbye, MD, MHPE, chief well-being officer at the University of Colorado Anschutz School of Medicine. “We have made gains. When I look at AAMC data, there’s some signal — maybe — that things are getting better or staying the same, not getting worse.”
The AAMC’s annual Graduation Questionnaire asks about burnout, quality of life, and stress, and the median rates have stayed consistent over the past five years.
“But the AAMC [questionnaire] is not measuring things like depression and anxiety, other domains of mental health,” Dyrbye adds.
Much progress has been made in helping individual students cope with challenges, including by teaching students about healthy habits and changing grading to pass-fail, she says.
“They’re important [steps], but by themselves they’re not enough,” Dyrbye says. “They’re helping students do the very best they can within the system they’re in, rather than attacking the system.”
Reducing the stigma
Lorna Breen, MD, was an emergency physician working at New York-Presbyterian Hospital in 2020 when the COVID-19 pandemic engulfed the city. Within weeks, hospitals in Manhattan were overwhelmed with people suffering and dying from this mysterious disease. Breen and her health care-worker colleagues struggled to find protective gear and risked their own health to treat countless patients for hours on end. The experience put Breen into a mental health crisis, but she told her sister that she was afraid to seek mental health care because she worried it would ruin her career. Breen died by suicide on April 26, 2020.
Her death, one of about 400 physician suicides that happen each year in the United States, laid bare the culture in medicine that still stigmatizes people experiencing mental distress.
The Dr. Lorna Breen Heroes’ Foundation, which was started by her family, was formed with the mission to promote well-being initiatives for health care workers and reduce the stigma around using them. One of the foundation’s key efforts has been lobbying state licensing boards to remove questions about mental health history from their applications.
“On these licensing and credentialing applications, clinicians shouldn’t have to disclose a history of mental health care that has no bearing on their ability to practice,” says Stefanie Simmons, MD, an emergency physician and chief medical officer for the foundation. “People make an economic decision. When you’ve invested a-quarter-to-half-a-million dollars in medical school debt, the perceived threat to your license or credentials—your ability to work—creates a significant deterrent to seeking care.”
As of January, 43 medical licensure boards had removed these questions, asking only about current impairment and not history.
Simmons says that, in the nearly two decades since she became a physician, the awareness around the mental health of medical professionals has come a long way, but there are still significant systemic barriers.
Dyrbye believes that the newest generation of medical students and doctors is already less likely to stigmatize asking for mental health help and more likely to speak up when their mental health is threatened. It’s an example from which more seasoned physicians can learn, she says. Taking breaks and asking for help are not signs of weakness; they are a necessity.
“I think it’s really about the shared responsibility. There are things students have to do; there’s a piece for the teaching faculty; there’s a piece for the dean; there’s a piece for the AAMC,” she says. “If we work together, we can make progress.”
